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Perioperative Echocardiography and Cardiovascular Education

Section Editor: Nikolaos J. Skubas


E SPECIAL ARTICLE
CME
The Nuts and Bolts of Performing Focused
Cardiovascular Ultrasound (FoCUS)
Josh M. Zimmerman, MD, FASE,* and Bradley J. Coker, MD

The benefit of focused cardiovascular ultrasound as an adjunct to physical examination has


been shown in numerous specialties and in diverse clinical settings. Although the value of
these techniques to the practice of anesthesiology is substantial, they have only begun to be
incorporated. This article reviews the basic techniques required to perform a bedside focused
cardiovascular ultrasound (ie, FoCUS examination). This includes a discussion of patient posi-
tioning, breath control, probe position, and manipulation and was supplemented by normal and
abnormal examples for review. (Anesth Analg 2017;124:75360)

T
his article reviews the basic techniques required to the pocket-sized devices often used for FoCUS cannot be
perform a focused cardiovascular ultrasound (FoCUS) expected to have the same image quality and resolution of
examination at the bedside. It begins with indications, a full-service platform. The FoCUS examination is neither
limitations, and equipment, then describes in detail the nuts comprehensive nor designed to make quantitative assess-
and bolts of physically performing the examination. For each ments.1 Subtle abnormalities may be overlooked, and there
of the views, there is a discussion of patient positioning and may be uncertainty regarding the severity of abnormali-
technique, a brief review of anatomy, and examples of normal ties that are identified. There is a natural tendency to place
and abnormal images. This article is also accompanied by a a high value on what can be seen, and the practitioner of
Supplemental Video tutorial that demonstrates the techniques FoCUS needs to be careful to neither lock in nor exclude
described herein (Supplemental Digital Content, http:// diagnoses based on limited ultrasound information. The
links.lww.com/AA/B686). Obviously, no article is adequate findings of an examination always should be taken in
to train a provider without a background in cardiovascular context, with a healthy suspicion that the interpretation
ultrasound. The goal of this article is not to provide compre- could be flawed or incomplete and with a low threshold
hensive education but rather a solid introduction and refer- to request a second opinion or a formal echocardiogram to
ence for further practice. A broader description of the history, confirm findings.
application, value, and training required for anesthesiologists
to perform these techniques has been published separately. EQUIPMENT AND ULTRASOUND PROBE SELECTION
FoCUS should be seen as an extension of the physical Focused ultrasound can be performed with any of a variety of
examination rather than as a limited version of a compre- ultrasound machines, from the stand-alone full-service echo-
hensive echocardiogram. When viewed in this light, ultra- cardiography platforms, to smaller portable machines, to the
sound can expand dramatically the diagnostic potential of smallest pocket-sized ultrasound devices. It is not the type
the bedside evaluation. Although there are numerous poten- of machine that defines focused ultrasound but the training
tial reasons to perform FoCUS, the most common indica- of the provider and the scope of the clinical questions being
tions in the perioperative period include signs or symptoms addressed. Any ultrasound system can be used so long as it
of heart failure and hemodynamic instability. The diagnos- meets the following requirements: availability of a 2-dimen-
tic targets of FoCUS include evaluation of cardiac structure, sional phased array (cardiac) probe of appropriate frequency
biventricular systolic function, valvular function, pericar- for adult patients; the ability to record date, time, and patient
dial effusion, and volume status. identifiers with the images; and the ability to adjust gain and
It is important that physicians performing FoCUS depth. The availability of M-mode, color flow Doppler, spec-
have a clear understanding of the limitations inherent to tral Doppler imaging, and measurement tools are not required
the techniques, as well as the limitations of their individ- for a FoCUS examination.1,2 Electrocardiogram (ECG) capa-
ual level of skill, training, and experience. Furthermore, bility is not required for FoCUS, and some machines may not
From the *Department of Anesthesiology, University of Utah, Salt Lake be able to display ECG. When machines with this capability
City, Utah; and Department of Perioperative Medicine and Anesthesiology, are used, however, ECG leads should be connected to ensure
University of Alabama at Birmingham, Birmingham, Alabama.
that images are acquired appropriately.
Accepted for publication November 28, 2016.
Funding: None.
The authors declare no conflicts of interest.
ULTRASOUND PROBE TERMINOLOGY
Because the language used to describe ultrasound probe
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions of manipulation is not standardized, the terminology used in
this article on the journals website (www.anesthesia-analgesia.org). this article needs to be defined. For cardiac ultrasound, the
Reprints will not be available from the authors. probe is held in the left hand so that the right hand can be
Address correspondence to Josh M. Zimmerman, MD, FASE, Department of used to manipulate the machine. All probes will have an
Anesthesiology, University of Utah, 30 North 1900 East, Room 3C444, Salt
Lake City, UT 84132. Address e-mail to joshua.zimmerman@hsc.utah.edu. indicator, generally a light or a notch, that corresponds to
Copyright 2017 International Anesthesia Research Society an orientation marker, usually a dot, on the ultrasound
DOI: 10.1213/ANE.0000000000001861 image. For cardiac ultrasound, the orientation marker is on

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E SPECIAL ARTICLE

the right of the ultrasound image. Although probe orienta-


tion can be confusing for new bedside ultrasonographers, it
need not be. The ultimate goal is to create the correct orien-
tation on the screen. If the image appears reversed, simply
rotate the probe 180. When describing probe motion, the
authors will use the following terminology:

Sliding. Motion of the probe to a different position on the body.


This will also be described as window shopping. This is done
to find the optimal position from which to image, particularly
when trying to scan between ribs. The sliding motion can be
done to move from one interspace to another (larger motions),
or to optimize imaging at a given interspace (small motions).
Tilting. With the probe kept at the same location on the
body, a rocking motion is applied to the probe to image
different structures within the same plane (Figure1). This is
done most commonly to center an image on the screen and
represents a motion of the tail or cord of the transducer
toward or away from the probes indicator.
Angulation. With the probe kept at the same location on the Figure 1. Ultrasound probe manipulation nomenclature. Tilt moves
the probe in the plane of the ultrasound beam, angle moves the
body, the transducer is moved side-to-side to create new probe perpendicular to the beam (creating new planes parallel to the
imaging planes relatively parallel to the original plane. This original), and rotate turns the probe like a key in a lock.
motion will be at angles perpendicular to the tilting motion.
Rotation. With the probe otherwise held still, it is turned
around its central axis similar to turning a key in a lock.

ULTRASOUND IMAGE TERMINOLOGY


Window. The term window is used to describe the location
of the ultrasound probe. Just like a window in a house, this
is what the transducer transducer looks through to see the
heart. The 3 windows described in FoCUS are parasternal,
apical, and subcostal (Figure2).
Plane. This is the anatomic plane or cross section of the
heart that is made by the ultrasound beam. The 3 planes
used for the FoCUS examination are the long axis, short
axis, and 4 chamber.
1. Long axis: Parallel to the long axis of the left ventricle
(LV), simultaneously intersecting the apex of the LV,
the center of the aortic valve (AV), and the center of Figure 2. The heart in the chest, with the sternum and ribs to pro-
the mitral valve in the anteriorposterior dimension. vide orientation. The 3 windows are indicated by the yellow dots.
2. Short axis: Perpendicular to the long axis of the ven-
tricle, showing a circular cross section of the ventricle.
Depth. The depth of scanning for each image should be set
In the case of FoCUS, the LV short axis will be at the
to include the structures of interest and nothing else (as
level of the papillary muscles.
shown in the video examples). Inappropriately increas-
3. Four chamber: Perpendicular to the short axis, this
ing the depth of scanning both makes relevant structures
plane simultaneously transects the apex of the LV, both
appear smaller and results in an image that is refreshed less
ventricles and atria, and the mitral and tricuspid valves.
frequently with less temporal resolution and quality.
View. A combination of window and plane used to describe
Gain. This setting affects the displayed brightness of the
a particular image. For instance, the parasternal long-axis
ultrasound image. Gain should be set so that blood appears
(PLAX) view is made from the parasternal window and
black rather than gray. A reasonable setting could be
transects the heart in the long axis plane.
achieved by turning gain up until blood appears gray, then
decreasing it slightly.
KNOBOLOGY AND IMAGE OPTIMIZATION
A detailed understanding of ultrasound physics is not nec- Time-Gain Compensation. Some ultrasound systems offer the
essary for the practitioner of FoCUS; however, some under- ability to automatically adjust gain to optimize the display
standing of image optimization will prove useful. The and to provide uniform brightness throughout the image
following settings are available on many of the simplest rather than an image that becomes darker at increasing depth
ultrasound devices. due to the lower strength of the returned signal. Sometimes

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The Nuts and Bolts of Performing FoCUS

referred to as the make it better button, it can be a quick


way to improve the gain and image display settings.

PARASTERNAL WINDOW
Patient Positioning. A complete FoCUS examination often
can be performed in the supine patient, and clinical situa-
tions in which patients cannot be turned will be encountered
frequently. Parasternal imaging, however, would ideally be
performed in the full left-lateral decubitus position, with the
patients left arm extended. It is often comfortable for patient
to rest their left forearms under their head (Figure3). For all
FoCUS imaging, the ultrasonographer should be positioned on
the patients left side with the probe held in the left hand, leav-
ing the right hand free to manipulate the ultrasound machine.
Breath Control. Imaging from every window is better if Figure 3. Optimal patient positioning for the parasternal window.
patients can breathe shallowly. In spontaneously ventilat- The patient is in the left lateral decubitus position with his left arm
extended.
ing patients, parasternal images are often best at end-exha-
lation when there is less lung interposed between the probe
and the heart. If possible, having patients briefly hold their
breath at a low lung volume can improve imaging from the
parasternal window. The authors technique is to instruct
the patient to Take a deep breath in, now breathe all the
way out and hold ithold ithold itnow breathe. This
reminds the patient not to begin breathing in until adequate
images have been obtained. In intubated patients, it can help
to briefly pause the ventilator to allow a passive exhalation.

Parasternal Long Axis (Supplemental Digital


Content, Video 1, http://links.lww.com/AA/B611)
Probe Position and Manipulation. The PLAX image is made
with the probe placed just to the left of the sternum in the
third to fifth intercostal space with the indicator pointed
toward the patients right shoulder (Figure 4). The tech-
nique referred to by the authors as window shopping
should be used. This entails moving the probe briefly across Figure 4. Probe position for the parasternal long axis (PLAX.) The
the left parasternal interspaces to select the one that pro- probe is just to the left of the sternum, in the fourth intercostal
vides the best image. After identifying the best window, space (though this location will vary), with the indicator pointing
toward the patients right shoulder. The indicator location and direc-
small changes in rotation, tilt, and angle should be made to
tion is shown by the yellow arrow.
optimize the image.
Anatomy. The PLAX shows the right ventricular outflow
tract (RVOT), the AV and proximal ascending aorta, the left
atrium, mitral valve, and the basal and mid segments of the
anteroseptal and inferolateral walls of the LV (Supplemental
Digital Content, Video 1, http://links.lww.com/AA/B611;
Figure5).
Assessment. A great deal of valuable information is avail-
able from the PLAX image. The authors recommend a con-
sistent approach to evaluating this image, starting with the
RVOT and moving clockwise.
1. Right ventricle (RV): Although this image is not the
best to quantify the size or function of the RV, the
sonographer can get a sense of significant RV enlarge-
ment or dysfunction. The RVOT should appear simi-
lar in size to the aortic root in this view. As discussed
previously, all assessment of chamber size with
FoCUS is qualitative but nonetheless valuable. Figure 5. Anatomy of the PLAX. At the top of the screen, closest to
the ultrasound probe, is the right ventricular outflow tract (RVOT).
2. AV: The structure and opening of the AV can be Moving clockwise, the aortic valve (AV) and proximal ascending aorta
assessed. A valve that opens well, even if calcified, is (Ao) are seen, then the left atrium (LA), mitral valve (MV) and left
not likely to have clinically significant stenosis. An AV ventricle (LV). PLAX indicates parasternal long axis.

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E SPECIAL ARTICLE

that is heavily calcified and opens poorly should alert by the filling and emptying of the LV and LA, brisk
the provider to the possibility of significant aortic ste- opening of the anterior mitral leaflet in diastole, and
nosis (Supplemental Digital Content, Video 2, http:// the descent of the base of the LV toward the apex, rep-
links.lww.com/AA/B612). resenting the piston-like effect of longitudinal myo-
3. Left atrium: A qualitative assessment of left atrial size cardial fibers. Decreased global function will be seen
can be obtained by visually comparing the diameter of as decreased aortic root excursion, decreased excur-
the atrium to that of the aortic root. A left atrium that sion of the anterior mitral leaflet, decreased descent
is much larger than the aortic root suggests a history of the base of the MV, and decreased thickening of the
of elevated left atrial pressures (from diastolic dys- myocardium (Supplemental Digital Content, Video 4,
function, mitral valve disease, or atrial fibrillation). http://links.lww.com/AA/B614).
(Supplemental Digital Content, Video 2, http://links. 6. Effusions: Pericardial effusion can sometimes be identi-
lww.com/AA/B612). fied in this view and can be distinguished from pleu-
4. Mitral valve: A normal mitral valve should open ral effusion based on the relationship of the fluid to
briskly in diastole and should close completely in sys- the descending thoracic aorta. A pericardial effusion
tole, with no portion of the valve prolapsing above will come between the aorta and the heart, whereas
the annulus in this view. Leaflet tissue that extends a left pleural effusion will appear behind the aorta
above the annulus in systole suggests mitral valve (toward the bottom of the image) (Supplemental Digital
prolapse or flail (Supplemental Digital Content, Content, Video 7, http://links.lww.com/AA/B617). To
Video 3, http://links.lww.com/AA/B613). An ante- ensure that effusion is not overlooked, the sonographer
rior mitral leaflet that does not open briskly and come should begin imaging the PLAX with adequate depth
near the anteroseptal wall in diastole should alert the to visualize at least 5 cm beyond the descending aorta.
provider to the possibility of decreased cardiac out-
put or mitral stenosis (Supplemental Digital Content, Parasternal Short Axis (PSAX) (Supplemental
Video 4, http://links.lww.com/AA/B614). Mitral Digital Content, Video 8, http://links.lww.com/
annular calcification (MAC), particularly at the base AA/B618)
of the posterior leaflet, is a common finding in patients Probe Position and Manipulation. Starting with the PLAX
with hypertension, vascular disease, and renal fail- view, the short-axis image is made by keeping the probe in
ure (Supplemental Digital Content, Video 2, http:// the same location and rotating 90 clockwise so the indica-
links.lww.com/AA/B612). Because MAC affects the tor points toward the patients left shoulder (Figure6).
base of the valve rather than the coaptation, it is a Anatomy. The PSAX view transects the left and right ven-
rare cause of hemodynamically significant stenosis. tricles at the level of the papillary muscles (the mid-portion
Rheumatic mitral valve disease, on the other hand, of the LV). The short-axis section is like slices in a loaf of
affects the subvalvular apparatus, commissures, bread. The mid-segments of each of the 6 ventricular walls
and coaptation early in the disease process and cre- can be seen, representing myocardial territories perfused by
ates what is described as a hockey stick deformity each of the 3 main coronary arteries (Figure7).
with stenosis resulting from a much smaller degree
of leaflet thickening (Supplemental Digital Content, Assessment. The PSAX gives important information about
Video 5, http://links.lww.com/AA/B615). Another global and regional ventricular function and filling and is
important abnormality that can be identified from useful particularly in the hemodynamically unstable patient.
the PLAX is systolic anterior motion (SAM) of the
anterior leaflet of the mitral valve. The identification
of SAM should alert the practitioner to the possibil-
ity of dynamic left ventricular outflow tract obstruc-
tion. This pathology can be seen in hypertrophic
cardiomyopathy but also can be seen in patients with
small, thick ventricles and abnormal mitral leaflet tis-
sue. The findings can be subtle but should be sought
when patients present with hemodynamic instability,
syncope, or heart failure symptoms. It should be sus-
pected when a portion of the mitral valve appears to
be drawn into the left ventricular outflow tract during
late systole (Supplemental Digital Content, Video 6,
http://links.lww.com/AA/B616).
5. LV: Although only a portion of the anteroseptal and
inferolateral walls are viewed in this image, a good
sense of global and regional function can be obtained
in the PLAX. There should be brisk thickening of the Figure 6. Probe position for the parasternal short axis (PSAX.) The
probe is just to the left of the sternum, in the fourth intercostal
myocardium in systole. Other qualitative signs of space (though this location will vary), with the indicator pointing
normal global LV systolic function include a brisk toward the patients left shoulder. The indicator location and direc-
anteriorposterior motion of the aortic root caused tion is shown by the yellow arrow.

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The Nuts and Bolts of Performing FoCUS

ominous sign that is often seen in severe pulmonary


hypertension (Supplemental Digital Content, Video
12, http://links.lww.com/AA/B622).

APICAL WINDOW
Patient Positioning. Like the parasternal window, the apical
window is best imaged with the patient in the left lateral
decubitus position. Apical images are often more challeng-
ing than parasternal images when performed in the supine
position and even a small amount of left tilt of the patient
can improve the images. This can be achieved in some
cases by a towel or pillow bump under the right side of the
patient. With the patient in the full left-lateral decubitus
position, it can be challenging to place the ultrasound probe
at the true apex. This problem can result in an image with
the right ventricle at the apex of the screen, giving the false
impression of RV enlargement. This can be overcome either
by moving the patient all the way to the edge of the bed or
Figure 7. Anatomy of the PSAX. The right ventricle is seen on the left by tipping the patient slightly back from a true left lateral
side of the screen and defines the 2 septal walls of the left ventricle. position.
The papillary muscles are seen, identifying this as the midportion of
the ventricle. Six segments of the ventricle are shown, representing Breath Control. Unlike the parasternal window, the opti-
distributions of all 3 coronary arteries. A, mid-anterior segment of the mal lung volume for apical images is less predictable. The
LV; AL indicates mid-anterolateral segment of the LV; AS, mid-antero-
septal segment of the LV; I, mid-inferior segment of the LV; IL, mid- LV apex generally moves slightly caudally as the patient
inferolateral segment of the LV; IS, mid-inferoseptal segment of the inhales. After finding a reasonable window, the patient can
LV; LV, left ventricle; PSAX, parasternal short axis; RV, right ventricle. be asked to breathe in or out slowly until the best apical
image is achieved. They can then be asked to hold their
1. LV: In a ventricle with normal regional function, the breath using the same hold ithold ithold it, now
PSAX will have symmetrical thickening of each of the breathe technique described earlier.
myocardial segments. Decreased thickening (hypo-
kinesis) or absence of thickening (akinesis) suggests Apical 4-Chamber (A4) (Supplemental Digital
coronary ischemia or infarction. Typically, the left Content, Video 13, http://links.lww.com/AA/
anterior descending coronary artery perfuses the B623)
anterior portion of the LV, the circumflex coronary Probe Position and Manipulation. The A4 image generally is
artery perfuses the lateral portion of the ventricle, and more challenging than the parasternal or subcostal images.
the right coronary artery perfuses the inferior portion The first step is to identify the correct window for imaging.
of the ventricle (Supplemental Digital Content, Video Again, this will involve a degree of window shopping. In
9, http://links.lww.com/AA/B619). In hypovolemic some cases, palpation of the point of maximal impulse can
states, the LV will appear relatively small in diastole be useful, though the authors generally identify the apex
with hyperdynamic systolic function (Supplemental with ultrasound alone. The apex is usually just inferior
Digital Content, Video 10, http://links.lww.com/ and lateral to the nipple in men, and under the inferolat-
AA/B620). In low afterload states, the ventricle will eral quadrant of the left breast in women. Starting slightly
be fuller in diastole but will still be empty in systole medial to the expected location and moving the probe ceph-
reflecting increased cardiac output (Supplemental alad and caudad over several interspaces while slowly slid-
Digital Content, Video 11, http://links.lww.com/ ing laterally can help identify the apex. For the 4-chamber
AA/B621). plane, the probe indicator will be often be pointed to the 5
2. Right ventricle: The right ventricle is not the focus of oclock position when viewed from above (Figure8).
the PSAX, but if it appears significantly larger than
Anatomy. The apex of the LV should be at the top of the
the LV, it should trigger further evaluation of the RV
screen. The inferoseptal and anterolateral walls of the LV
from the apical 4 chamber.
can be seen, and 6 myocardial segments (basal, mid-, and
3. Interventricular septum (IVS): The behavior and
apical) can be identified. The longer anterior mitral leaflet
position of the IVS can give important information
can be seen medially with the shorter posterior leaflet later-
about the balance of pressures in the two ventricles.
ally. The right ventricle can be seen as well, with the tricus-
Normally the LV appears circular throughout the
pid valve displaced slightly toward the apex relative to the
cardiac cycle, reflecting the fact that LV pressures are
mitral valve. The left and right atrial should be visualized at
higher than RV pressures. If the IVS is flat in diastole
the bottom of the image (Figure 9).
but returns to normal (concave to the LV) in systole, it
suggests an RV volume overload state (often tricuspid Assessment.
regurgitation.) If the IVS stays flattened throughout 1. Left ventricle: This is another excellent view to assess
systole and diastole, it suggests a pressure overload global and regional left ventricular systolic function.
state of the RV.3 Septal flattening in systole is an A normal ventricle will have symmetrical thickening,

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E SPECIAL ARTICLE

a brisk opening of the mitral valve, and a brisk descent


of the mitral valve toward the LV apex (Supplemental
Digital Content, Video 13, http://links.lww.com/
AA/B623). Ischemia or infarction of the left anterior
descending coronary artery can often be recognized
in this view as wall motion abnormalities in the api-
cal portion of the ventricle (Supplemental Digital
Content, Video 14, http://links.lww.com/AA/B624).
2. Mitral valve: The leaflets of a normal valve should
remain below the mitral annulus with adequate
coaptation in systole. Significant prolapse or flail,
or an obvious lack of valve coaptation should raise
the possibility of significant mitral regurgitation
(Supplemental Digital Content, Video 15, http://
links.lww.com/AA/B625). MAC and rheumatic
valve changes can also be identified, as described
in the PLAX assessment (Supplemental Digital Figure 8. Probe position for the apical 4 chamber. The patient is in
Content, Video 2, http://links.lww.com/AA/B612; the left lateral decubitus position with their left arm extended. The
and Supplemental Digital Content, Video 16, http:// probe is located just inferior and lateral to the left nipple, with the
links.lww.com/AA/B626). indicator pointed toward 5 oclock (as viewed from above.) The indi-
cator location and direction is shown by the yellow arrow.
3. Atria: The relative sizes of the atria can be assessed
qualitatively in this view. They should be similar in
size and should be not appear larger than the ventri-
cles in diastole (Supplemental Digital Content, Video
16, http://links.lww.com/AA/B626).
4. Right ventricle: This is the preferred view to assess
RV size and global systolic function.3 The RV should
appear smaller than the LV in the A4, and the apex
of the heart should be made up of only LV. An RV
that contributes to the apex or that appears simi-
lar in size to the LV in this view is an indication of
RV enlargement. A normal RV will have thicken-
ing of the free wall and a brisk descent of the base
of the tricuspid valve toward the apex in systole
(Supplemental Digital Content, Video 17, http://
links.lww.com/AA/B627).
5. Tricuspid valve: This is also the preferred view
to assess structure and function of the tricuspid
valve. A normal TV will open fully in diastole, and
will remain below the annulus with good coapta-
tion in systole. The appearance of significant pro-
lapse or a lack of valve coaptation should suggest
the presence of significant tricuspid regurgitation
(Supplemental Digital Content, Video 18, http://
links.lww.com/AA/B628).

SUBCOSTAL WINDOW
Patient Positioning. Subcostal images are obtained with the
patient in the supine position. In patients who are awake,
the tone of the abdominal muscles can occasionally make
imaging difficult. In these cases, the patient should place a
Figure 9. Anatomy of the apical 4 chamber. The apex of the LV
pillow behind his/her knees or rest his/her feet on the bed. should be under the probe, and the right and left atria and ventricles
should be seen as well as the mitral and tricuspid valves. LA indi-
cates left atrium; LV, left ventricle; MV, mitral valve; RA, right atrium;
Subcostal 4-Chamber (SC4) (Supplemental RV, right ventricle; TV, tricuspid valve.
Digital Content, Video 19, http://links.lww.com/
AA/B629) to be, but to make the best subcostal images the liver needs to be
Probe Position and Manipulation. The subcostal window is used as the window rather than the stomach or spleen. To cre-
usually found 1 to 2 cm below the xiphoid process or slightly ate the SC4 image, the probe is placed on the abdomen nearly
to the right of midline. There is a tendency for the probe to drift horizontally with the indicator pointing directly to the patients
toward the patients left because this is where the heart is known left (Figure 10). The technique of creating the subcostal window

758
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The Nuts and Bolts of Performing FoCUS

Figure 10. Probe position for the subcostal 4 chamber. The patient is
supine with a pillow under his/her knees to relax the abdominal mus-
cles. The probe is 1 to 2 cm below the xiphoid process with the indica-
tor pointing directly toward the patients left (toward the sonographer.)
The indicator location and direction is shown by the yellow arrow.

Figure 12. Probe position for the subcostal IVC image. The probe is
12 cm below the xiphoid process with the indicator pointing toward
the patients head. The indicator location and direction is shown by
the yellow arrow. IVC indicates inferior vena cava.

portion of the right ventricle, and although it may show the


inferoseptal and anterolateral walls of the LV, this is less pre-
dictable. The benefit of this view is that it shows the free wall
of the right ventricle very well. It is a view that complements
the information obtained from the other windows. For some
Figure 11. Anatomy of the subcostal 4 chamber. The liver is at the patients, particularly those with tubes and drains or those
top of the screen. The right and left atria and ventricles can be visu- with severe chronic obstructive pulmonary disease, the sub-
alized, along with the mitral and tricuspid valves. It should be noted costal window may be the only one that provides adequate
that this is not the same cross-section as the apical 4 chamber. imaging, and a detailed 2D assessment of the cardiac struc-
LA indicates left atrium; LV, left ventricle; MV, mitral valve; RA, right
atrium; RV, right ventricle; TV, tricuspid valve. tures can often be obtained from this window alone.

Assessment.
for this image is reminiscent of placing a subclavian central line. 1. Right ventricle: The SC4 is an excellent view to assess
The probe is pushed down into the abdomen and forward to global RV systolic function as described earlier.
create a window that looks toward the heart (located directly Although an RV that appears larger than the LV in
under the ribs) rather than a window that looks down into the this view likely represent RV dilation, it is possible
abdomen. Slight changes in angulation and rotation are then for this image to underestimate the size of the right
used to create an appropriate SC4. ventricle (Supplemental Digital Content, Video 20,
http://links.lww.com/AA/B630). That means an RV
Breath Control. The subcostal 4 chamber can be improved
that appears normal in size from the SC4 could be
in some cases by having the patient take a partial or full
falsely reassuring.
breath in and hold it. As the diaphragm falls, the probe
2. Pericardial effusion: This is an excellent view to iden-
comes closer to the heart.
tify the presence of a pericardial effusion. An effusion
Anatomy. Although the view is called the subcostal 4 cham- will appear as an echolucent (dark) space around the
ber, and it may indeed show all 4 chambers of the heart, the right heart (Supplemental Digital Content, Video 21,
cross section is not identical to that obtained from the api- http://links.lww.com/AA/B631). Findings of tam-
cal window (Figure11). This view transects a more inferior ponade physiology may include right atrial inversion

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Copyright 2017 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
E SPECIAL ARTICLE

during ventricular systole, right ventricular compres- small appearing IVC suggests a patient that is likely vol-
sion during diastole, and inferior vena cava (IVC) ume responsive (Supplemental Digital Content, Video 24,
dilation (see next section.) As with other complex http://links.lww.com/AA/B634). Because assessment of
clinical scenarios, findings of effusion and tamponade volume status is one of the more complex aspects of cardiac
should be evaluated within the clinical context. ultrasound, it is important to view this information in the
broader clinical context and not to use IVC assessment as
Subcostal IVC Long Axis (Supplemental Digital the sole determinant.
Content, Video 22, http://links.lww.com/AA/
B632) IMAGE STORAGE AND REPORTING
Probe Position and Manipulation. Starting from the SC4, The days when perioperative echocardiographers could
the probe should be tilted to center the right atrium in the make images, act on the findings, store no images, and
screen. Then a slow counterclockwise rotation of the probe report no findings are gone. At this early stage of the adop-
by 60 to 90 should show the IVC entering the right atrium. tion of point-of-care ultrasound, the authors recommend
(Figure12). applying the current standards for medical imaging to all
forms of point-of-care ultrasound and to FoCUS in particu-
Anatomy. At the top of the image is the liver, with the IVC
lar. That means images should always be archived, either on
appearing near-horizontal on the screen as it enters the
an imaging server or on disks, for review and quality assur-
right atrium. It is important to distinguish the IVC from
ance. Every currently available ultrasound device has some
the abdominal aorta in this view. The aorta is thick-walled
mechanism for image storage. Likewise, there should be
and will often have obviously systolic pulsatility. The IVC is
some mechanism for reporting the findings of each FoCUS
thin-walled, can be seen to enter the right atrium, and has
examination. Paper forms can be used (an example used by
hepatic veins draining into it. The left hepatic vein can often
the authors is included in the Supplemental Digital Content,
be identified entering the IVC at the 12-oclock position near
http://links.lww.com/AA/B687), electronic forms can be
the right atrium (Figure 13).
created, or information can be reported in the anesthetic
Assessment. The utility of this view is to evaluate the
record.
relative size and behavior of the IVC to aid in the assess-

CONCLUSIONS
The field of perioperative echocardiography is broad, com-
plex, and takes years to master. FoCUS, on the other hand,
can provide significant value in the care of complex patients
with substantially less time and experience. This article pro-
vides a brief introduction to the techniques of FoCUS and
the reader with further interest is strongly encouraged to
seek further instruction. E

DISCLOSURES
Name: Josh M. Zimmerman, MD, FASE.
Contribution: This author was the primary author, and was respon-
sible for writing and editing this article.
Name: Bradley J. Coker, MD.
Contribution: This author helped with the writing and editing of
the article.
This article was handled by: Nikolaos J. Skubas, MD, DSc, FACC, FASE.

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